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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610133
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:33:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230728091118
FACILITY NAME:REM CALIFORNIA LLC - NAPAFACILITY NUMBER:
197610133
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:16214 NAPA STTELEPHONE:
(909) 483-2505
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gboyega Akinbola- AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff is physically abusing resident in care.
INVESTIGATION FINDINGS:
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On 08/03/23 Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Administrator Gboyega Akinbola and explained the reason for the visit.

Allegation: Staff is physically abusing resident in care.

It is alleged that R1 is being physically abused by staff while in care. LPA conducted an interview with the Administrator regarding the allegation. Interview revealed that R1 has aggressive condition where resident unexpectly and unreasonbly gets agressive and angry. Due to R1's condition LPAs were unable to interview R1. LPAs attempted to interview three (3) out of four (4) they were not responsive. Administrator provided three (3) Incidents Reports that revelas R1's incident of agressiveness towards staff.
(Continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20230728091118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - NAPA
FACILITY NUMBER: 197610133
VISIT DATE: 08/03/2023
NARRATIVE
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LPAs attempted to interview Staff#1 (S1) they were off duty of today's visit. LPAs obtained copies of Individual Face Sheet, Special Incident Reports, Annual Progress Report, and Physician's Report.

Based on the information obtained, there was insufficient evidence to confirm the allegation occurred.

This allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2